Lifestyle Interventions with Mind-Body or Stress-Management Practices for Cancer Survivors: A Rapid Review

This rapid review examined current evidence on lifestyle interventions with stress-management or mind-body practices that assessed dietary and/or physical activity outcomes among cancer survivors. Searches were conducted in PubMed, Embase, and PsycINFO based on Cochrane Rapid Reviews Methods Group rapid review recommendations using the keywords “diet,” “physical activity,” “mind-body,” “stress,” and “intervention.” Of the 3624 articles identified from the initial search, 100 full-text articles were screened, and 33 articles met the inclusion criteria. Most studies focused on post-treatment cancer survivors and were conducted in-person. Theoretical frameworks were reported for five studies. Only one study was tailored for adolescent and young adult (AYA) cancer survivors, and none included pediatric survivors. Nine studies reported race and/or ethnicity; six reported that ≥90% participants were White. Many reported significant findings for diet and/or physical activity-related outcomes, but few used complete, validated dietary intake methods (e.g., 24-h recall; n = 5) or direct measures of physical activity (e.g., accelerometry; n = 4). This review indicated recent progress on evaluating lifestyle interventions with stress-management or mind-body practices for cancer survivors. Larger controlled trials investigating innovative, theory-based, personalized interventions that address stress and health behaviors in cancer survivors—particularly racial/ethnic minority and pediatric and AYA populations—are needed.


Introduction
Cancer incidence rates are growing worldwide [1], and five-year survival rates have dramatically increased since the 1970s for several types of cancer [2]. As the number of cancer survivors with comorbid conditions, including hypertension, diabetes, and morbid obesity, has also risen in recent decades [3], lifestyle interventions are needed to reduce the risk of chronic disease and improve the quality of life among cancer survivors [4]. The American Cancer Society and the World Cancer Research Fund/American Institute for Cancer Research recommend healthy eating and physical activity to improve cancer prognosis and survival [5,6]. Adherence to nutrition and physical activity guidelines has been associated with a 10-61% decrease in overall cancer incidence and mortality, with consistent reductions in breast, endometrial, and colorectal cancer, in particular [7].
However, cancer survivors face numerous stressors that may impact their ability to make healthy lifestyle behavior choices. Cancer survivors often experience psychological distress in the form of anxiety, post-traumatic stress disorder (PTSD), fear of cancer recurrence, or depressive symptoms [8]. Psychosocial stress is known to alter dietary and physical activity behaviors in the general population [9][10][11], and prolonged stress may exacerbate endocrine dysfunction, including hypothalamic-pituitary-adrenal (HPA) axis disruption, experienced by many cancer survivors [12]. Mind-body therapies, including 2 of 18 meditation and yoga, and other stress-management interventions may help to manage stress [13] and address unmet psychosocial needs among cancer survivors [14]. Yoga, meditation, qigong, mindfulness-based stress reduction (MBSR), and massage have been used as complementary medical therapies for cancer patients [15], and mindfulness-based stress reduction training interventions have been shown to improve the quality of life of cancer survivors [16].
Interventions that address nutrition or physical activity in addition to mind-body therapies may improve healthy lifestyle behaviors among cancer survivors [17][18][19], yet research on such interventions is limited. Given the potential for mind-body therapy and stress reduction to further improve the health and well-being of cancer survivors, there is a need to assess the effects of lifestyle interventions that address such practices in this population. There is a lack of reviews investigating the prevalence of such interventions.
Whereas systematic reviews often take up to two years to complete, rapid reviews streamline systematic review methods to more quickly complete reviews with comparable aims [20]. The purpose of this study was to conduct a rapid review of the literature on the prevalence of lifestyle interventions (i.e., diet and/or physical activity interventions) that address stress-management or mind-body practices and assess diet and/or physical activity-related outcomes among cancer survivors.

Selection Criteria
Searches were conducted in PubMed, Embase, and PsycINFO based on recommendations from the Cochrane Rapid Reviews Methods Group (CRRMG) [20]. The searches were not restricted by publication date. The National Center for Complementary and Integrative Health (NCCIH) mind and body practices (i.e., acupuncture, massage therapy, meditation, relaxation techniques, spinal manipulation, tai chi, and yoga) were used to inform our inclusion criteria for mind-body practices [21]. The inclusion criteria were as follows: (1) participants diagnosed with cancer prior to study enrollment; (2) lifestyle intervention (i.e., diet and/or physical activity intervention) addressing stress-management or mind-body practices; (3) intervention study design (e.g., clinical trial, one-group pre-post); and (4) quantitative measure of dietary intake, physical activity, or physical fitness (e.g., muscular strength, walking distance), including both objective and subjective measures. For our selection criteria, yoga, tai chi, and qigong were defined as mind-body practices rather than physical activity. Studies were limited to publications in English based on CRRMG guidelines [20]. The exclusion criteria were as follows: (1) cancer diagnosis not mentioned in the article's study inclusion criteria; (2) feeding studies; (3) non-intervention study (e.g., observational, case-control); and (4) protocol paper, conference paper, abstract, letter, or commentary. Multiple papers on the same intervention were allowed if different samples were used in order to describe all samples and outcomes used for each intervention identified. The protocol was registered in PROSPERO during the initial search process (CRD42022307760).

Search Strategy
The search strategy was developed by A.W.B., with initial assistance from a research librarian. The keywords "diet," "physical activity," "mind-body," "stress," and "intervention" were searched using natural language and controlled vocabulary in PubMed, Embase, and PsycINFO. The Systematic Review Accelerator (SR-Accelerator) from the Institute for Evidence-Based Healthcare at Bond University was used to remove unnecessary terms from the search [22]. For example, NCCIH terms (e.g., "acupuncture," "massage") were initially used as keywords, but were removed from the search using the SR-Accelerator. Such terms were still used to identify relevant articles during the screening process. The full search strategy is depicted in Table S1. Screening was conducted according to CRRMG guidelines [20]. The searches were conducted on 16 March 2022.

Screening Process
After pilot title/abstract screening, all retrieved articles were manually reviewed by A.W.B. based on inclusion and exclusion criteria with a dual screen of 20% of abstracts by S.L.C. After pilot full-text screening, one reviewer (A.W.B.) first screened all full-text articles, and a second reviewer (E.R.) further screened all full-text articles to confirm whether they met the inclusion criteria. Discrepancies were resolved through discussion with a third reviewer (T.L.C.) until a consensus was reached. The PRISMA flowchart for the study is depicted in Figure 1. The full search strategy is depicted in Table S1. Screening was conducted according to CRRMG guidelines [20]. The searches were conducted on 16 March 2022.

Screening Process
After pilot title/abstract screening, all retrieved articles were manually reviewed by A.W.B. based on inclusion and exclusion criteria with a dual screen of 20% of abstracts by S.L.C. After pilot full-text screening, one reviewer (A.W.B.) first screened all full-text articles, and a second reviewer (E.R.) further screened all full-text articles to confirm whether they met the inclusion criteria. Discrepancies were resolved through discussion with a third reviewer (T.L.C.) until a consensus was reached. The PRISMA flowchart for the study is depicted in Figure 1.

Data Extraction
The following data were extracted to Microsoft Excel by a single reviewer (A.W.B.): primary investigator(s), country, publication year, purpose/aim, study design and methods, participant age, type of cancer, timing of study relative to cancer diagnosis, total sample size, intervention and setting, theoretical framework, dietary assessment, physical activity assessment, assessment of psychological (e.g., stress, anxiety, depression) and quality of life (QOL) variables, and study outcomes. A second reviewer (E.R.) checked the extracted data for correctness and completeness. The two reviewers discussed and checked the data extraction together, and a third reviewer (S.L.C.) further reviewed the data extraction results for clarity and completeness.

Study Quality Assessment
Study quality assessment was examined using the National Heart, Lung, and Blood Institute (NHLBI) Study Quality Assessment Tools for controlled intervention studies (14 items) and pre-post studies with no control group (12 items) [23]. Due to the large number

Data Extraction
The following data were extracted to Microsoft Excel by a single reviewer (A.W.B.): primary investigator(s), country, publication year, purpose/aim, study design and methods, participant age, type of cancer, timing of study relative to cancer diagnosis, total sample size, intervention and setting, theoretical framework, dietary assessment, physical activity assessment, assessment of psychological (e.g., stress, anxiety, depression) and quality of life (QOL) variables, and study outcomes. A second reviewer (E.R.) checked the extracted data for correctness and completeness. The two reviewers discussed and checked the data extraction together, and a third reviewer (S.L.C.) further reviewed the data extraction results for clarity and completeness.

Study Quality Assessment
Study quality assessment was examined using the National Heart, Lung, and Blood Institute (NHLBI) Study Quality Assessment Tools for controlled intervention studies (14 items) and pre-post studies with no control group (12 items) [23]. Due to the large number of studies identified in this review, two reviewers independently rated the risk of bias (A.W.B. and E.R.) and resolved discrepancies between judgments and support statements through discussion. Quality was categorized as "Good," "Fair," or "Poor" based on the guidelines. Mean scores between the two reviewers were considered as a summary score, but the categorization of "Good," "Fair," or "Poor" involved consideration of the risk of potential biases beyond the score itself [23]. Studies were not excluded based on quality assessment.

Data Synthesis
Data were synthesized narratively by two reviewers (A.W.B. and E.R.) to demonstrate the overall level of evidence and degree of consistency in findings, with verification of judgments by all other co-authors (S.L.C., M.S., and T.L.C.). Tables were used to summarize the study characteristics. A meta-analysis was not conducted due to the heterogeneity of the studies identified in this review.

Results
There were 3624 articles identified from the initial search ( Figure 1). After screening by title, 984 duplicates were removed, and 2540 were further excluded by title and abstract screening. The remaining 100 articles underwent full-text screening. After further excluding 67 articles, 33 met all criteria for inclusion in the final list.

Overview of Interventions
As some studies discussed the same interventions, there were 26 distinct interventions in this review. Most interventions (n = 23) were conducted in-person or did not specify the setting. Some mentioned specific materials, such as a video, booklet, and audio recording [30]. Three included telephone counseling [18,29,48]. Three interventions included diet and mind-body practices, 11 included physical activity and mind-body practices, and 12 included diet, physical activity, and mind-body practices. A few interventions included comprehensive sessions that focused on multiple health behaviors together (e.g., diet, physical activity, and smoking or diet, physical activity, and stress management), rather than including separate components. Diet components included counseling and cooking classes. Mind-body components included complementary therapies (e.g., meditation, yoga, massage, relaxation, Tai Chi) and stress-management counseling. Physical activity components included aerobic and resistance training, walking, and stretching/mobilization. The intervention length ranged from one visit with take-home materials to one year (mean 11 weeks). Theoretical frameworks, reported in five studies, included the Transtheoretical Model [18,26,48], Lazarus and Folkman's Transactional Model of Stress and Coping [29,40], Social Cognitive Theory [18,26], and Salmon's unifying theory of physical activity [40]. Descriptions of the interventions are included in Table 2. ≤6 months post-treatment remission NR = not reported; P = pooled analysis of two or more RCTs; PA = physical activity; PPI = pre-/post-intervention; RCT = randomized controlled trial. a Group means.
Fifteen studies used direct physical activity measures only, seven used self-report measures only, and seven used both direct and self-report measures. Physical activity assessment tools included accelerometry (n = 4), 7-day Physical Activity Recall (PAR) (n = 3), the Community Health Activities Model Program for Seniors (CHAMPS) Physical Activity Questionnaire (n = 3), the Godin-Shephard Leisure-Time Physical Activity Questionnaire (GSLTPAQ) (n = 1), and step tracking using electronic pedometers (n = 1). Physical capacity was evaluated through walking tests (n = 14) (6-min (n = 11), 12-min (n = 1), 50-foot (n = 1), and one-mile (n = 1) walking tests) and VO 2 max (n = 7) and submax (n = 1) tests. Tests for physical strength included hand-held dynamometers measuring grip strength (n = 3), the Short Physical Performance Battery (SPPB) (n = 3), and one-rep maximums (1RM) (n = 2). Tests for flexibility and stability were used in only one study and included the toe touch test, back scratch test, chair-stand test, stand and reach test, single limb stance test, and range of motion (ROM) test. Other measures are included in Table 3.      Table 3.

Quality Assessment
The 16 controlled intervention studies had a mean quality rating of 10/14, with eight studies rated as Good and eight rated as Fair. Six had ≥20% attrition or did not report a dropout rate, and seven had inadequate details on their randomization method. Among the 17 pre-post-intervention studies, 10 were rated as Good, and seven were rated as Fair; only one had sufficient sample size to provide confidence in findings; only one mentioned that those assessing outcomes were blinded to the exposure/intervention; and only two used an interrupted time-series design. The mean rating was 7.8/12. The results of the quality assessment are summarized in Table 4.

Discussion
This review identified 33 studies on lifestyle interventions (diet and/or physical activity) that addressed stress-management or mind-body practices for cancer survivors. Most studies focused on post-treatment cancer survivors, were conducted in-person, and/or were conducted with participants from a wide age range. None included pediatric cancer survivors, and only one intervention was tailored for AYA survivors. Nine studies reported participants' race and/or ethnicity, and all nine indicated that ≥70% of the participants were White. Many reported significant findings for diet and/or physical activity-related outcomes, but few used complete, validated dietary intake methods (e.g., 24-h recall; n = 5) or direct measures of physical activity (e.g., accelerometry; n = 4). All studies identified in this review were categorized as Good or Fair quality based on NHLBI Study Quality Assessment Tools. However, most pre-post interventions were limited by a small sample size, and 63% of controlled interventions had high attrition (≥20%) or did not report attrition.
The findings indicated a lack of interventions for pediatric and AYA cancer survivors. Compared to other cancer survivors, AYA cancer survivors have an increased risk of anxiety, cancer-related worry, post-traumatic stress symptoms [55], and mood disturbances [8]. Although lifestyle interventions show promise for changing health behaviors among pediatric and AYA cancer survivors [56,57], existing interventions do not address the burden of psychosocial stress, which may impact these behaviors. Research is warranted to adequately tailor interventions for younger populations that have unique psychosocial and developmental needs.
Most of the studies with one health behavior component (i.e., diet or physical activity) assessed behavioral outcomes and reported significant findings. Even though 14 studies (42%) included comprehensive interventions that incorporated diet, physical activity, and mind-body practices, 10 of the 14 (71%) did not report diet and/or physical activity outcomes. Future research may incorporate multiple health behaviors into their intervention evaluation, as well as intervention design, to adequately assess behavior change.
Six of the nine studies that assessed weight-related outcomes reported significant findings, indicating a need for larger studies with metabolic outcomes (e.g., blood glucose levels, blood pressure).
The findings highlight a need for rigorous measures of diet and physical activity for interventions. Real-world dietary intake is often assessed with self-report measures, such as 24-h dietary recalls, food records, and FFQs [58]. Many studies in this review used screeners or selected questions from validated measures; only five used dietary recall or FFQs. None used Weighed Food Records (WFR), the "gold standard" for dietary assessment [59]. More studies (n = 22) used direct measures of physical activity; seven studies collected self-reported data as their only source of physical activity data. None of the studies used bio-behavioral assessments for psychological and QOL variables, such as cortisol, to measure stress.
The limitations of this review included the rapid review methodology. Although much of the rapid review methodology is similar to that of a systematic review, relevant studies may have been missed due to the limitations of a rapid review (e.g., not reviewing journal indexes or gray literature; the second reviewer screened only 20% of identified studies, including only three databases). Additionally, studies were restricted to those published in English, limiting the generalizability of findings. A meta-analysis was not conducted due to heterogeneity regarding age, cancer type, time since treatment, outcomes, intervention type, and length. Although this review focused on lifestyle interventions that address stress-management or mind-body practices for cancer survivors, the authors recognize that characterizing yoga, tai chi, and qigong as mind-body practices rather than physical activity may limit finding interpretability across physical activity outcomes. These activities were characterized based on the NCCIH definition of mind and body practices.
[21] Future reviews may examine the effects of yoga, tai chi, and qigong interventions alone on physical activity outcomes. Additionally, there was reporting bias in this review, as multiple papers on the same intervention were included if different samples and outcomes were used. These articles were grouped together in Table 2 for transparency.
Despite its limitations, this review followed the CRRMG recommendations for conducting rapid reviews to complete a streamlined synthesis of knowledge on lifestyle interventions that address stress-management or mind-body practices among cancer survivors. To analyze the 33 studies identified, the research team adopted systematic review protocols for study quality assessment and data synthesis and used a longer, more rigorous approach to data extraction than is recommended by the CRRMG.

Conclusions
This review indicated recent progress on evaluating lifestyle interventions that address stress-management or mind-body practices among cancer survivors. The results suggest a need for larger controlled studies with standardized measures of psychological, behavioral, and metabolic outcomes. The findings further highlight a need for tailored interventions, specifically for racial/ethnic minority survivors and pediatric and AYA survivors, who are underrepresented in the literature. Further research should investigate innovative, theorybased, personalized interventions that address stress and health behaviors among cancer survivors. Future studies may also compare the effects of various lifestyle interventions with and without stress-management or mind-body practices (e.g., whether interventions targeting multiple health behaviors are more effective at improving mental health outcomes than interventions targeting a single health behavior or whether lifestyle interventions with stress-management or mind-body practices are more effective at improving health behaviors than lifestyle interventions alone).